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Muttini S, Jona Falco J, Cuevas Cairo I, Umbrello M. A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm. J Clin Med 2024; 13:1120. [PMID: 38398433 PMCID: PMC10889278 DOI: 10.3390/jcm13041120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure. METHODS Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure. RESULTS Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success. CONCLUSION In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.
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Affiliation(s)
- Stefano Muttini
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Jacopo Jona Falco
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Ilmari Cuevas Cairo
- Department of Anaesthesia and Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy;
| | - Michele Umbrello
- Department of Intensive care and Anaesthesia, Ospedale Civile di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
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Aljohani H, Russell D, Kim YI, Bassler J, Lowman J. The Neuromechanics of Inspiratory Muscles in Mechanical Ventilation Liberation Success and Failure. Cureus 2024; 16:e51570. [PMID: 38313921 PMCID: PMC10835747 DOI: 10.7759/cureus.51570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Assessing the neuromechanical coupling of inspiratory muscles during mechanical ventilation (MV) could reveal the physiological mechanism of MV failure. This study examined the respiratory neuromechanical characteristics between MV liberation success and failure. METHODS This is an observational prospective study that included patients during their ventilator liberation process. Assessment of surface electromyography (sEMG) of inspiratory muscles, including the diaphragm and extra-diaphragmatic (scalene, sternocleidomastoid, and parasternal) muscles, was performed 15 minutes after the initiation of spontaneous breathing trials. Neuromechanical efficiency of the diaphragm (NMEDia) and extra-diaphragmatic muscles (NMEExtra) were compared in patients who were successfully liberated from MV with those who failed MV liberation within 72 hours after extubation. RESULTS A total of 45 patients were enrolled and 28 were female (67%). The sample median age was 63 (IQR 47, 69) years old. One-third of patients failed MV liberation within 72 hours of their spontaneous breathing trials (SBTs). NMEDia was significantly lower in patients who failed MV liberation with a root mean square of (M 0.27), (IQR 0.21, 0.37) compared with (M 0.371), (IQR 0.3, 0.631) for the success group (p=0.0222). The area under the curve for NMEDia was lower in the failure group (M 0.270), (IQR 0.160, 0.370) and (M 0.485), (IQR 0.280, 0.683) for the success group (p=0.024). However, NMEExtra was not statistically different between the two groups. CONCLUSION Reduced NMEDia is a predictor of MV liberation failure. NMEExtra was not a major contributor to MV liberation outcomes. Further studies should assess the performance of inspiratory muscles NME indices to predict MV liberation outcomes.
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Affiliation(s)
- Hassan Aljohani
- Respiratory Therapy Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Derek Russell
- Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Young-Il Kim
- Preventive Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - John Bassler
- Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - John Lowman
- Physical Therapy, University of Alabama at Birmingham, Birmingham, USA
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Docci M, Rezoagli E, Teggia-Droghi M, Coppadoro A, Pozzi M, Grassi A, Bianchi I, Foti G, Bellani G. Individual response in patient's effort and driving pressure to variations in assistance during pressure support ventilation. Ann Intensive Care 2023; 13:132. [PMID: 38123757 PMCID: PMC10733248 DOI: 10.1186/s13613-023-01231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND During Pressure Support Ventilation (PSV) an inspiratory hold allows to measure plateau pressure (Pplat), driving pressure (∆P), respiratory system compliance (Crs) and pressure-muscle-index (PMI), an index of inspiratory effort. This study aims [1] to assess systematically how patient's effort (estimated with PMI), ∆P and tidal volume (Vt) change in response to variations in PSV and [2] to confirm the robustness of Crs measurement during PSV. METHODS 18 patients recovering from acute respiratory failure and ventilated by PSV were cross-randomized to four steps of assistance above (+ 3 and + 6 cmH2O) and below (-3 and -6 cmH2O) clinically set PS. Inspiratory and expiratory holds were performed to measure Pplat, PMI, ∆P, Vt, Crs, P0.1 and occluded inspiratory airway pressure (Pocc). Electromyography of respiratory muscles was monitored noninvasively from body surface (sEMG). RESULTS As PSV was decreased, Pplat (from 20.5 ± 3.3 cmH2O to 16.7 ± 2.9, P < 0.001) and ∆P (from 12.5 ± 2.3 to 8.6 ± 2.3 cmH2O, P < 0.001) decreased much less than peak airway pressure did (from 21.7 ± 3.8 to 9.7 ± 3.8 cmH2O, P < 0.001), given the progressive increase of patient's effort (PMI from -1.2 ± 2.3 to 6.4 ± 3.2 cmH2O) in line with sEMG of the diaphragm (r = 0.614; P < 0.001). As ∆P increased linearly with Vt, Crs did not change through steps (P = 0.119). CONCLUSION Patients react to a decrease in PSV by increasing inspiratory effort-as estimated by PMI-keeping Vt and ∆P on a desired value, therefore, limiting the clinician's ability to modulate them. PMI appears a valuable index to assess the point of ventilatory overassistance when patients lose control over Vt like in a pressure-control mode. The measurement of Crs in PSV is constant-likely suggesting reliability-independently from the level of assistance and patient's effort.
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Affiliation(s)
- Mattia Docci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Maddalena Teggia-Droghi
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Andrea Coppadoro
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alice Grassi
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Isabella Bianchi
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy.
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento Largo Medaglie d'Oro Trento, Trento, Italy.
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Abstract
Advanced respiratory monitoring involves several mini- or noninvasive tools, applicable at bedside, focused on assessing lung aeration and morphology, lung recruitment and overdistention, ventilation-perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator asynchrony, in dealing with acute respiratory failure. Compared to a conventional approach, advanced respiratory monitoring has the potential to provide more insights into the pathologic modifications of lung aeration induced by the underlying disease, follow the response to therapies, and support clinicians in setting up a respiratory support strategy aimed at protecting the lung and respiratory muscles. Thus, in the clinical management of the acute respiratory failure, advanced respiratory monitoring could play a key role when a therapeutic strategy, relying on individualization of the treatments, is adopted.
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Pettenuzzo T, Sella N, Zarantonello F, De Cassai A, Geraldini F, Persona P, Pistollato E, Boscolo A, Navalesi P. How to recognize patients at risk of self-inflicted lung injury. Expert Rev Respir Med 2022; 16:963-971. [PMID: 36154791 DOI: 10.1080/17476348.2022.2128335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patient self-inflicted lung injury (P-SILI) has been proposed as a form of lung injury caused by strong inspiratory efforts consequent to a high respiratory drive in patients with hypoxemic acute respiratory failure (hARF). Increased respiratory drive and effort may lead to variable combinations of deleterious phenomena, such as excessive transpulmonary pressure, pendelluft, intra-tidal recruitment, local lung volutrauma, and pulmonary edema. Gas exchange and respiratory mechanics derangements further increase respiratory drive and effort, thus inducing a vicious circle. Forms of partial ventilatory support may further add to the detrimental effects of P-SILI. Since P-SILI may worsen patient outcome, strategies aimed at identifying and preventing P-SILI would be of great importance. AREAS COVERED We systematically searched Pubmed since inception until 15 April 2022 to review the patho-physiological mechanisms of P-SILI and the strategies to identify those patients at risk of P-SILI. EXPERT OPINION Although the concept of P-SILI has been increasingly supported by experimental and clinical data, no study has insofar demonstrated the efficacy of any strategy to identify it in the clinical setting. Further research is thus needed to ascertain the detrimental effects of spontaneous breathing and identify patients with hARF at high risk of developing P-SILI.
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Affiliation(s)
- Tommaso Pettenuzzo
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Francesco Zarantonello
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Alessandro De Cassai
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Federico Geraldini
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Persona
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Elisa Pistollato
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy.,Department of Medicine, University of Padua, Padua, Italy
| | - Annalisa Boscolo
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Navalesi
- Department of Surgery, Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Italy.,Department of Medicine, University of Padua, Padua, Italy
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Gurumahan V, Thavalingam S, Schindler T, Smyth J, Lui K, Bolisetty S. Reference values for diaphragm electrical activity (Edi) in newborn infants. BMC Pediatr 2022; 22:559. [PMID: 36151518 PMCID: PMC9502911 DOI: 10.1186/s12887-022-03619-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Neurally adjusted ventilatory assist is an emerging mode of respiratory support that uses the electrical activity of the diaphragm (Edi) to provide synchronised inspiratory pressure support, proportional to an infant’s changing inspiratory effort. Data on Edi reference values for neonates are limited. The objective of this study was to establish reference Edi values for preterm and term neonates who are not receiving respiratory support. Methods This was a prospective observational study of newborn infants breathing spontaneously in room air. The Edi waveform was monitored by a specialised naso/orogastric feeding tube with embedded electrodes positioned at the level of the diaphragm. Edi minimums and peaks were recorded continuously for 4 h without changes to routine clinical handling. Results Twenty-four newborn infants (16 preterm [< 37 weeks’ gestation]; 8 term) were studied. All infants were breathing comfortably in room air at the time of study. Edi data were successfully captured in all infants. The mean (±SD) Edi minimum was 3.02 (±0.94) μV and the mean Edi peak was 10.13 (±3.50) μV. In preterm infants the mean (±SD) Edi minimum was 3.05 (±0.91) μV and the mean Edi peak was 9.36 (±2.13) μV. In term infants the mean (±SD) Edi minimum was 2.97 (±1.05) μV and the mean Edi peak was 11.66 (±5.14) μV. Conclusion Reference Edi values were established for both preterm and term neonates. These values can be used as a guide when monitoring breathing support and when using diaphragm-triggered modes of respiratory support in newborn infants Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03619-1.
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Affiliation(s)
| | - Sriganesh Thavalingam
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tim Schindler
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - John Smyth
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - Kei Lui
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - Srinivas Bolisetty
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia. .,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia.
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Umbrello M, Antonucci E, Muttini S. Neurally Adjusted Ventilatory Assist in Acute Respiratory Failure-A Narrative Review. J Clin Med 2022; 11:jcm11071863. [PMID: 35407471 PMCID: PMC9000024 DOI: 10.3390/jcm11071863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023] Open
Abstract
Maintaining spontaneous breathing has both potentially beneficial and deleterious consequences in patients with acute respiratory failure, depending on the balance that can be obtained between the protecting and damaging effects on the lungs and the diaphragm. Neurally adjusted ventilatory assist (NAVA) is an assist mode, which supplies the respiratory system with a pressure proportional to the integral of the electrical activity of the diaphragm. This proportional mode of ventilation has the theoretical potential to deliver lung- and respiratory-muscle-protective ventilation by preserving the physiologic defense mechanisms against both lung overdistention and ventilator overassistance, as well as reducing the incidence of diaphragm disuse atrophy while maintaining patient–ventilator synchrony. This narrative review presents an overview of NAVA technology, its basic principles, the different methods to set the assist level and the findings of experimental and clinical studies which focused on lung and diaphragm protection, machine–patient interaction and preservation of breathing pattern variability. A summary of the findings of the available clinical trials which investigate the use of NAVA in acute respiratory failure will also be presented and discussed.
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Mojoli F, Pozzi M, Orlando A, Bianchi IM, Arisi E, Iotti GA, Braschi A, Brochard L. Timing of inspiratory muscle activity detected from airway pressure and flow during pressure support ventilation: the waveform method. Crit Care 2022; 26:32. [PMID: 35094707 PMCID: PMC8802480 DOI: 10.1186/s13054-022-03895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Whether respiratory efforts and their timing can be reliably detected during pressure support ventilation using standard ventilator waveforms is unclear. This would give the opportunity to assess and improve patient–ventilator interaction without the need of special equipment.
Methods In 16 patients under invasive pressure support ventilation, flow and pressure waveforms were obtained from proximal sensors and analyzed by three trained physicians and one resident to assess patient’s spontaneous activity. A systematic method (the waveform method) based on explicit rules was adopted. Esophageal pressure tracings were analyzed independently and used as reference. Breaths were classified as assisted or auto-triggered, double-triggered or ineffective. For assisted breaths, trigger delay, early and late cycling (minor asynchronies) were diagnosed. The percentage of breaths with major asynchronies (asynchrony index) and total asynchrony time were computed. Results Out of 4426 analyzed breaths, 94.1% (70.4–99.4) were assisted, 0.0% (0.0–0.2) auto-triggered and 5.8% (0.4–29.6) ineffective. Asynchrony index was 5.9% (0.6–29.6). Total asynchrony time represented 22.4% (16.3–30.1) of recording time and was mainly due to minor asynchronies. Applying the waveform method resulted in an inter-operator agreement of 0.99 (0.98–0.99); 99.5% of efforts were detected on waveforms and agreement with the reference in detecting major asynchronies was 0.99 (0.98–0.99). Timing of respiratory efforts was accurately detected on waveforms: AUC for trigger delay, cycling delay and early cycling was 0.865 (0.853–0.876), 0.903 (0.892–0.914) and 0.983 (0.970–0.991), respectively. Conclusions Ventilator waveforms can be used alone to reliably assess patient’s spontaneous activity and patient–ventilator interaction provided that a systematic method is adopted. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03895-4.
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Graßhoff J, Petersen E, Farquharson F, Kustermann M, Kabitz HJ, Rostalski P, Walterspacher S. Surface EMG-based quantification of inspiratory effort: a quantitative comparison with P es. Crit Care 2021; 25:441. [PMID: 34930396 PMCID: PMC8686581 DOI: 10.1186/s13054-021-03833-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
Background Inspiratory patient effort under assisted mechanical ventilation is an important quantity for assessing patient–ventilator interaction and recognizing over and under assistance. An established clinical standard is respiratory muscle pressure \documentclass[12pt]{minimal}
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\begin{document}$$\textit{P}_{\mathrm{mus}}$$\end{document}Pmus, derived from esophageal pressure (\documentclass[12pt]{minimal}
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\begin{document}$$\textit{P}_{\mathrm{es}}$$\end{document}Pes), which requires the correct placement and calibration of an esophageal balloon catheter. Surface electromyography (sEMG) of the respiratory muscles represents a promising and straightforward alternative technique, enabling non-invasive monitoring of patient activity. Methods A prospective observational study was conducted with patients under assisted mechanical ventilation, who were scheduled for elective bronchoscopy. Airway flow and pressure, esophageal/gastric pressures and sEMG of the diaphragm and intercostal muscles were recorded at four levels of pressure support ventilation. Patient efforts were quantified via the \documentclass[12pt]{minimal}
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\begin{document}$$\textit{P}_{\mathrm{mus}}$$\end{document}Pmus-time product (\documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus), the transdiaphragmatic pressure-time product (\documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{di}}$$\end{document}PTPdi) and the EMG-time products (ETP) of the two sEMG channels. To improve the signal-to-noise ratio, a method for automatically selecting the more informative of the sEMG channels was investigated. Correlation between ETP and \documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus was assessed by determining a neuromechanical conversion factor \documentclass[12pt]{minimal}
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\begin{document}$$\textit{K}_{\mathrm{EMG}}$$\end{document}KEMG between the two quantities. Moreover, it was investigated whether this scalar can be reliably determined from airway pressure during occlusion maneuvers, thus allowing to quantify inspiratory effort based solely on sEMG measurements. Results In total, 62 patients with heterogeneous pulmonary diseases were enrolled in the study, 43 of which were included in the data analysis. The ETP of the two sEMG channels was well correlated with \documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus (\documentclass[12pt]{minimal}
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\begin{document}$$\textit{r}={0.79\pm 0.25}$$\end{document}r=0.79±0.25 and \documentclass[12pt]{minimal}
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\begin{document}$$\textit{r}={0.84\pm 0.16}$$\end{document}r=0.84±0.16 for diaphragm and intercostal recordings, respectively). The proposed automatic channel selection method improved correlation with \documentclass[12pt]{minimal}
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\begin{document}$$\textit{r}={0.87\pm 0.09}$$\end{document}r=0.87±0.09). The neuromechanical conversion factor obtained by fitting ETP to \documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus varied widely between patients (\documentclass[12pt]{minimal}
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\begin{document}$$\textit{K}_{\mathrm{EMG}}= {4.32\pm 3.73}\,{\hbox {cm}\hbox {H}_{2}\hbox {O}/\upmu \hbox {V}}$$\end{document}KEMG=4.32±3.73cm2O/μV) and was highly correlated with the scalar determined during occlusions (\documentclass[12pt]{minimal}
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\begin{document}$$\textit{p}<{.001}$$\end{document}p<.001). The occlusion-based method for deriving \documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus from ETP showed a breath-wise deviation to \documentclass[12pt]{minimal}
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\begin{document}$${\mathrm{PTP}}_{\mathrm{mus}}$$\end{document}PTPmus of \documentclass[12pt]{minimal}
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\begin{document}$${0.43\pm 1.73}\,{\hbox {cm}\hbox {H}_{2}\hbox {O}\,\hbox {s}}$$\end{document}0.43±1.73cm2Os across all datasets. Conclusion These results support the use of surface electromyography as a non-invasive alternative for monitoring breath-by-breath inspiratory effort of patients under assisted mechanical ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03833-w.
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Affiliation(s)
- Jan Graßhoff
- Institute for Electrical Engineering in Medicine, Universität zu Lübeck, Moislinger Allee 53-55, 23558, Lübeck, Germany. .,Fraunhofer Research Institution for Individualized and Cell-Based Medical Engineering, Mönkhofer Weg 239 a, 23562, Lübeck, Germany.
| | - Eike Petersen
- Institute for Electrical Engineering in Medicine, Universität zu Lübeck, Moislinger Allee 53-55, 23558, Lübeck, Germany
| | | | - Max Kustermann
- Medical Clinic II, Klinikum Konstanz, Mainaustraße 35, 78464, Konstanz, Germany
| | - Hans-Joachim Kabitz
- Medical Clinic II, Klinikum Konstanz, Mainaustraße 35, 78464, Konstanz, Germany
| | - Philipp Rostalski
- Institute for Electrical Engineering in Medicine, Universität zu Lübeck, Moislinger Allee 53-55, 23558, Lübeck, Germany.,Fraunhofer Research Institution for Individualized and Cell-Based Medical Engineering, Mönkhofer Weg 239 a, 23562, Lübeck, Germany
| | - Stephan Walterspacher
- Medical Clinic II, Klinikum Konstanz, Mainaustraße 35, 78464, Konstanz, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455, Witten, Germany
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10
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Haudebourg AF, Maraffi T, Tuffet S, Perier F, de Prost N, Razazi K, Mekontso Dessap A, Carteaux G. Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors. Ann Intensive Care 2021; 11:147. [PMID: 34669080 PMCID: PMC8527439 DOI: 10.1186/s13613-021-00935-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Background Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering. Design Observational assessment followed by prospective cross-over physiological study. Setting Academic medical ICU. Patients Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study. Interventions Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH2O. Measurements Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments. Results Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH2O [12–18] with a PEEP of 7 cmH2O [5–8] and FiO2 of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs. 22.7% [10.3–40.1], p < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH2O/s/min [79–131] under PSV vs. 149 cmH2O/s/min [129–170] under PAV+, p = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH2O/s/min [1–6] vs. 8 cmH2O/s/min [3–30], p = 0.012). Conclusions Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00935-0.
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Affiliation(s)
- Anne-Fleur Haudebourg
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France. .,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.
| | - Tommaso Maraffi
- Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Service de Réanimation et Surveillance Continue Adulte, Centre hospitalier intercommunal de Créteil, 94000, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - François Perier
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
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11
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Xiao S, Huang C, Cheng Y, Xia Z, Li Y, Tang W, Shi B, Wang L, Shu X, Jiang Y, Qin C, Xu H. Application of neurally adjusted ventilatory assist in ventilator weaning of infants ventilator weaning. Brain Behav 2021; 11:e2350. [PMID: 34520632 PMCID: PMC8553316 DOI: 10.1002/brb3.2350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/18/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND To analyze the application of neurally adjusted ventilatory assist in ventilator weaning of infants. METHODS A total of 25 infants (15 boys and 10 girls) who were mechanically ventilated by PICU in Hubei Maternal and Child Health Hospital were selected as the study subjects. After the improvement of the basic disease, regular spontaneous breathing, and the withdrawal of the ventilator, all the children obtained the electrical activity of the diaphragm (EAdi) signal. Then, each child was given CPAP and NAVA mode mechanical ventilation 1 h before the withdrawal of the ventilator. Each detection index was recorded 30 min after each mode of ventilation. RESULTS Two of the 25 children were tracheotomized because of respiratory muscle weakness and could not be converted to NAVA mode without the EAdi signal. Hemodynamic indexes were not statistically different between the two groups of CPAP and NAVA. PaCO2 is not significantly different in the two modes, and both were at normal levels. The PIP in NAVA mode is lower than that in CPAP mode (p < .05), and its EAdi signal was correspondingly low. There were significant differences in the peak pressure (Ppeak), mean pressure (Pmean), and compliance and mean arterial pressure (p < .01) between the CPAP and NAVA model ventilation in 23 patients. CONCLUSION NAVA can significantly improve the coordination of patients. The therapeutic effect of NAVA was better, which was beneficial to the prognosis of patients and had positive application value in the withdrawal of ventilators in patients.
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Affiliation(s)
- Shuna Xiao
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Chengjiao Huang
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Ying Cheng
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Zhi Xia
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Yong Li
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Wen Tang
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Buyun Shi
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Lijun Wang
- Department of Cardiac Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaolan Shu
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Ying Jiang
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Chenguang Qin
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
| | - Hui Xu
- Department of Pediatric Critical Medicine, Maternal and Child Health Care Hospital of Hubei Province, Wuhan, China
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12
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Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-Self Inflicted Lung Injury: A Practical Review. J Clin Med 2021; 10:jcm10122738. [PMID: 34205783 PMCID: PMC8234933 DOI: 10.3390/jcm10122738] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.
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Affiliation(s)
- Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
- Correspondence:
| | - Mélodie Parfait
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Margot Combet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
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13
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Sadek SH, El-kholy MM, Abdulmoez MS, El-Morshedy RM. Patient-ventilator asynchrony as a predictor of weaning failure in mechanically ventilated COPD patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [PMCID: PMC8267513 DOI: 10.1186/s43168-021-00076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients. It is associated with adverse effects including increased work of breathing, patient discomfort, increased need for sedation, prolonged mechanical ventilation, weaning difficulties, and weaning failure. The purpose of the present was to describe patient-ventilator asynchrony and its impact on weaning outcomes in mechanically ventilated chronic obstructive pulmonary disease (COPD) patients. Results One hundred mechanically ventilated COPD patients were enrolled in this prospective study. Weaning failure (need of NIV or reintubation within 48 h) was noticed in 27 (27%) patients while 73 (73%) patients had successful weaning. Patients with failed weaning had significantly higher asynchrony index (A.I) and ineffective trigger index (ITI) in comparison with those with successful weaning (7.69 ± 3.71, 3.46 ± 2.59 versus 6.27 ± 3.14, 2.47 ± 2.08, respectively; P value< 0.04). Data were expressed as mean ± standard deviation. Conclusion High asynchrony index and high ineffective trigger index may be early predictors of weaning failure in mechanically ventilated COPD patients.
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14
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van Leuteren RW, de Waal CG, Hutten GJ, de Jongh FH, van Kaam AH. Transcutaneous monitoring of diaphragm activity as a measure of work of breathing in preterm infants. Pediatr Pulmonol 2021; 56:1593-1600. [PMID: 33524225 PMCID: PMC8248030 DOI: 10.1002/ppul.25284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Monitoring work of breathing (WOB) is important to assess the pulmonary condition and adjust respiratory support in preterm infants. Conventional WOB measurement (esophageal pressure, tidal volume) is invasive and we hypothesized that monitoring diaphragm activity could be a noninvasive alternative to estimate WOB. The objective was to determine the correlation between conventional WOB measures and diaphragm activity, in preterm infants. METHODS WOB and diaphragm activity, measured with transcutaneous electromyography (dEMG), were simultaneously recorded at different nasal continuous positive airway pressure (nCPAP) levels. During a 30-s recording at each nCPAP level, dEMG parameters, inspiratory WOB (WOBi ), and pressure time product (PTPin ) were calculated per breath. The correlation coefficient between WOB- and dEMG-measures was calculated using single breaths and after aggregating all breaths into deciles of incremental WOBi . RESULTS Fifteen preterm infants were included (median gestational age, 28 weeks). Single-breath analysis showed a poor median correlation of 0.27 (interquartile range [IQR], 0.03 to 0.33) and 0.08 (IQR, -0.03 to 0.28), respectively, for WOBi and PTPin with peak diaphragmatic activity (dEMGpeak ). A modest median correlation coefficient of 0.65 (IQR, 0.13 to 0.79) and 0.43 (IQR, -0.33 to 0.69) was found for, respectively, WOBi and PTPin with dEMGpeak in the aggregated analysis. CONCLUSION Diaphragm activity showed a modest correlation with WOBi and PTPin in an aggregated analysis. This finding warrants further studies in infants with more significant lung disease.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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15
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Noto A, Crimi C, Cortegiani A, Giardina M, Benedetto F, Princi P, Carlucci A, Appendini L, Gregoretti C. Performance of EasyBreath Decathlon Snorkeling mask for delivering continuous positive airway pressure. Sci Rep 2021; 11:5559. [PMID: 33692464 PMCID: PMC7946943 DOI: 10.1038/s41598-021-85093-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
During the COVID-19 pandemic, the need for noninvasive respiratory support devices has dramatically increased, sometimes exceeding hospital capacity. The full-face Decathlon snorkeling mask, EasyBreath (EB mask), has been adapted to deliver continuous positive airway pressure (CPAP) as an emergency respiratory interface. We aimed to assess the performance of this modified EB mask and to test its use during different gas mixture supplies. CPAP set at 5, 10, and 15 cmH2O was delivered to 10 healthy volunteers with a high-flow system generator set at 40, 80, and 120 L min-1 and with a turbine-driven ventilator during both spontaneous and loaded (resistor) breathing. Inspiratory CO2 partial pressure (PiCO2), pressure inside the mask, breathing pattern and electrical activity of the diaphragm (EAdi) were measured at all combinations of CPAP/flows delivered, with and without the resistor. Using the high-flow generator set at 40 L min-1, the PiCO2 significantly increased and the system was unable to maintain the target CPAP of 10 and 15 cmH2O and a stable pressure within the respiratory cycle; conversely, the turbine-driven ventilator did. EAdi significantly increased with flow rates of 40 and 80 L min-1 but not at 120 L min-1 and with the turbine-driven ventilator. EB mask can be safely used to deliver CPAP only under strict constraints, using either a high-flow generator at a flow rate greater than 80 L min-1, or a high-performance turbine-driven ventilator.
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Affiliation(s)
- Alberto Noto
- Division of Anesthesia and Intensive Care, Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", University of Messina, Policlinico "G. Martino", Via Consolare Valeria, 1, 98100, Messina, Italy. .,IPCF-CNR, Institute for Chemical and Physical Processes, National Research Council, Messina, Italy.
| | - Claudia Crimi
- Respiratory Medicine Unit, "Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | | | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical, Dental Sciences and Morphofunctional Imaging, Policlinic "G. Martino", University of Messina, Messina, Italy
| | - Pietro Princi
- IPCF-CNR, Institute for Chemical and Physical Processes, National Research Council, Messina, Italy
| | - Annalisa Carlucci
- Department of Medicina e Chirurgia, Università Insubria Varese-Como, Varese, Italy.,Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Lorenzo Appendini
- ASL CN1, S.S.D. Fisiopatologia Respiratoria, Ospedale di Saluzzo, Saluzzo, CN, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,G. Giglio Foundation, Cefalù, Italy
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16
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Diaphragmatic activity and neural breathing variability during a 5-min endotracheal continuous positive airway pressure trial in extremely preterm infants. Pediatr Res 2021; 89:1810-1817. [PMID: 32942291 PMCID: PMC7533985 DOI: 10.1038/s41390-020-01159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Extremely preterm infants are often exposed to endotracheal tube continuous positive airway pressure (ETT-CPAP) trials to assess extubation readiness. The effects of ETT-CPAP trial on their diaphragmatic activity (Edi) and breathing variability is unknown. METHODS Prospective observational study enrolling infants with birth weight ≤1250 g undergoing their first extubation attempt. Diaphragmatic activity, expressed as the absolute minimum (Edi min) and maximum values (Edi max), area under the Edi signal, and breath-by-breath analyses for breath areas, amplitudes, widths, and neural inspiratory and expiratory times, were analyzed during mechanical ventilation (MV) and ETT-CPAP. Neural breathing variability of each of these parameters was also calculated and compared between MV and ETT-CPAP. RESULTS Thirteen infants with median (interquartile range) birth weight of 800 g [610-920] and gestational age of 25.4 weeks [24.4-26.3] were included. Diaphragmatic activity significantly increased during ETT-CPAP when compared to MV:Edi max (44.2 vs. 38.1 μV), breath area (449 vs. 312 μV·s), and amplitude (10.12 vs. 7.46 μV). Neural breathing variability during ETT-CPAP was characterized by increased variability for amplitude and area under the breath, and decreased for breath time and width. CONCLUSIONS A 5-min ETT-CPAP in extremely preterm infants undergoing extubation imposed significant respiratory load with changes in respiratory variability. IMPACT ETT-CPAP trials are often used to assess extubation readiness in extremely preterm infants, but its effects upon their respiratory system are not well known. Diaphragmatic activity analysis demonstrated that these infants are able to mount an important response to a short trial. A 5-min trial imposed a significant respiratory load evidenced by increased diaphragmatic activity and changes in breathing variability. Differences in breathing variability were observed between successful and failed extubations, which should be explored further in extubation readiness investigations. This type of trial cannot be recommended for preterm infants in clinical practice until clear standards and accuracy are established.
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17
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Hadfield D, Rose L, Reid F, Cornelius V, Hart N, Finney C, Penhaligon B, Harris C, Saha S, Noble H, Smith J, Hopkins PA, Rafferty GF. Factors affecting the use of neurally adjusted ventilatory assist in the adult critical care unit: a clinician survey. BMJ Open Respir Res 2020; 7:7/1/e000783. [PMID: 33293357 PMCID: PMC7725091 DOI: 10.1136/bmjresp-2020-000783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022] Open
Abstract
Background Neurally adjusted ventilatory assist (NAVA) involves an intricate interaction between patient, clinician and technology. To improve our understanding of this complex intervention and to inform future trials, this survey aimed to examine clinician attitudes, beliefs and barriers to NAVA use in critically ill adults within an institution with significant NAVA experience. Methods A survey of nurses, doctors and physiotherapists in four Intensive Care Units (ICUs) of one UK university-affiliated hospital (75 NAVA equipped beds). The survey consisted of 39 mixed open and structured questions. The hospital had 8 years of NAVA experience prior to the survey. Results Of 466 distributed questionnaires, 301 (64.6%) were returned from 236 nurses (78.4%), 53 doctors (17.6%) and 12 physiotherapists (4.0%). Overall, 207/294 (70.4%) reported clinical experience. Most agreed that NAVA was safe (136/177, 76.8%) and clinically effective (99/176, 56.3%) and most perceived ‘improved synchrony’, ‘improved comfort’ and ‘monitoring the diaphragm’ to be key advantages of NAVA. ‘Technical issues’ (129/189, 68.3%) and ‘NAVA signal problems’ (94/180, 52.2%) were the most cited clinical disadvantage and cause of mode cross-over to Pressure Support Ventilation (PSV), respectively. Most perceived NAVA to be more difficult to use than PSV (105/174, 60.3%), although results were mixed when compared across different tasks. More participants preferred PSV to NAVA for initiating ventilator weaning (93/171 (54.4%) vs 29/171 (17.0%)). A key barrier to use and a consistent theme throughout was ‘low confidence’ in relation to NAVA use. Conclusions In addition to broad clinician support for NAVA, this survey describes technical concerns, low confidence and a perception of difficulty above that associated with PSV. In this context, high-quality training and usage algorithms are critically important to the design and of future trials, to clinician acceptance and to the clinical implementation and future success of NAVA.
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Affiliation(s)
- Daniel Hadfield
- Critical Care Research, King's College Hospital, London, UK .,King's College London, Centre for Human and Applied Physiological Sciences, London, UK
| | - Louise Rose
- King's College London Florence Nightingale School of Nursing and Midwifery, London, London, UK.,Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Fiona Reid
- King's College London School of Population Health and Environmental Sciences, London, London, UK
| | | | - Nicholas Hart
- Centre for Human and Applied Physiological Sciences, King's College London School of Biomedical Sciences, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' Hospitals NHS Trust, London, London, UK
| | - Clare Finney
- Critical Care Research, King's College Hospital, London, UK
| | | | - Clare Harris
- Critical Care Research, King's College Hospital, London, UK
| | - Sian Saha
- Critical Care Research, King's College Hospital, London, UK
| | - Harriet Noble
- Critical Care Research, King's College Hospital, London, UK
| | - John Smith
- Critical Care Research, King's College Hospital, London, UK
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18
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Jonkman AH, Rauseo M, Carteaux G, Telias I, Sklar MC, Heunks L, Brochard LJ. Proportional modes of ventilation: technology to assist physiology. Intensive Care Med 2020; 46:2301-2313. [PMID: 32780167 PMCID: PMC7417783 DOI: 10.1007/s00134-020-06206-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/30/2020] [Indexed: 01/17/2023]
Abstract
Proportional modes of ventilation assist the patient by adapting to his/her effort, which contrasts with all other modes. The two proportional modes are referred to as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation with load-adjustable gain factors (PAV+): they deliver inspiratory assist in proportion to the patient’s effort, and hence directly respond to changes in ventilatory needs. Due to their working principles, NAVA and PAV+ have the ability to provide self-adjusted lung and diaphragm-protective ventilation. As these proportional modes differ from ‘classical’ modes such as pressure support ventilation (PSV), setting the inspiratory assist level is often puzzling for clinicians at the bedside as it is not based on usual parameters such as tidal volumes and PaCO2 targets. This paper provides an in-depth overview of the working principles of NAVA and PAV+ and the physiological differences with PSV. Understanding these differences is fundamental for applying any assisted mode at the bedside. We review different methods for setting inspiratory assist during NAVA and PAV+ , and (future) indices for monitoring of patient effort. Last, differences with automated modes are mentioned.
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Affiliation(s)
- Annemijn H Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Michela Rauseo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, F-94010, France.,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, F-94010, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, F-94010, France
| | - Irene Telias
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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19
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DI Nardo M, Lonero M, Staffieri F, DI Mussi R, Murgolo F, Lorusso P, Pham T, Picardo SG, Perrotta D, Cecchetti C, RavÀ L, Grasso S. Can visual inspection of the electrical activity of the diaphragm improve the detection of patient-ventilator asynchronies by pediatric critical care physicians? Minerva Anestesiol 2020; 87:319-324. [PMID: 32755090 DOI: 10.23736/s0375-9393.20.14543-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patient-ventilator asynchronies are challenging during pediatric mechanical ventilation. We hypothesized that monitoring the electrical activity of the diaphragm (EAdi) together with the "standard" airway opening pressure (Pao) and flow-time waveforms during pressure support ventilation would improve the ability of a cohort of critical care physicians to detect asynchronies in ventilated children. METHODS We recorded the flow, Pao and EAdi waveforms in ten consecutive patients. The recordings were split in periods of 15 s, each reproducing a ventilator screenshot. From this pool, a team of four experts selected the most representative screenshots including at least one of the three most common asynchronies (missed efforts, auto-triggering and double triggering) and split them into two versions, respectively showing or not the EAdi waveforms. The screenshots were shown in random order in a questionnaire to sixty experienced pediatric intensivists that were asked to identify any episode of patient-ventilator asynchrony. RESULTS Among the ten patients included in the study, only eight had EAdi tracings without artifacts and were analyzed. When the Eadi waveform was shown, the auto-triggering detection improved from 13% to 67% (P<0.0001) and the missed efforts detection improved from 43% to 95% (P<0.0001). The detection of double triggering, instead, did not improve (85% with the EAdi vs. 78% without the EAdi waveform; P=0.52). CONCLUSIONS This single center study suggests that the EAdi waveform may improve the ability of pediatric intensivists to detect missed efforts and auto-triggering asynchronies. Further studies are required to determine the clinical implications of these findings.
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Affiliation(s)
- Matteo DI Nardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Margherita Lonero
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy -
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Rosa DI Mussi
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Francesco Murgolo
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Pantaleo Lorusso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | | | - Sergio G Picardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Perrotta
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucilla RavÀ
- Unit of Epidemiology and Biostatistics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
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20
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Laghi F, Shaikh H, Littleton SW, Morales D, Jubran A, Tobin MJ. Inhibition of central activation of the diaphragm: a mechanism of weaning failure. J Appl Physiol (1985) 2020; 129:366-376. [PMID: 32673161 PMCID: PMC7473953 DOI: 10.1152/japplphysiol.00856.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
During a T-tube trial following disconnection of mechanical ventilation, patients failing the trial do not develop contractile diaphragmatic fatigue despite increases in inspiratory pressure output. Studies in volunteers, patients, and animals raise the possibility of spinal and supraspinal reflex mechanisms that inhibit central-neural output under loaded conditions. We hypothesized that diaphragmatic recruitment is submaximal at the end of a failed weaning trial despite concurrent respiratory distress. Tidal transdiaphragmatic pressure (ΔPdi) and electrical activity (ΔEAdi) were recorded with esophago-gastric catheters during a T-tube trial in 20 critically ill patients. During the T-tube trial, ∆EAdi was greater in weaning failure patients than in weaning success patients (P = 0.049). Despite increases in ΔPdi, from 18.1 ± 2.5 to 25.9 ± 3.7 cm H2O (P < 0.001), rate of transdiaphragmatic pressure development (from 22.6 ± 3.1 to 37.8 ± 6.7 cm H2O/s; P < 0.0004), and concurrent respiratory distress, ∆EAdi at the end of a failed T-tube trial was half of maximum, signifying inhibition of central neural output to the diaphragm. The increase in ΔPdi in the weaning failure group, while ∆EAdi remained constant, indicates unexpected improvement in diaphragmatic neuromuscular coupling (from 46.7 ± 6.5 to 57.8 ± 8.4 cm H2O/%; P = 0.006). Redistribution of neural output to the respiratory muscles characterized by a progressive increase in rib cage and accessory muscle contribution to tidal breathing and expiratory muscle recruitment contributed to enhanced coupling. In conclusion, diaphragmatic recruitment is submaximal at the end of a failed weaning trial despite concurrent respiratory distress. This finding signifies that reflex inhibition of central neural output to the diaphragm contributes to weaning failure. NEW & NOTEWORTHY Research into pathophysiology of failure to wean from mechanical ventilation has excluded several factors, including contractile fatigue, but the precise mechanism remains unknown. We recorded transdiaphragmatic pressure and diaphragmatic electrical activity in patients undergoing a T-tube trial. Diaphragmatic recruitment was submaximal at the end of a failed trial despite concurrent respiratory distress, signifying that inhibition of central neural output to the diaphragm is an important mechanism of weaning failure.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Stephen W Littleton
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Daniel Morales
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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21
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Roesthuis LH, van der Hoeven JG, van Hees HWH, Schellekens WJM, Doorduin J, Heunks LMA. Recruitment pattern of the diaphragm and extradiaphragmatic inspiratory muscles in response to different levels of pressure support. Ann Intensive Care 2020; 10:67. [PMID: 32472272 PMCID: PMC7256918 DOI: 10.1186/s13613-020-00684-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/16/2020] [Indexed: 01/16/2023] Open
Abstract
Background Inappropriate ventilator assist plays an important role in the development of diaphragm dysfunction. Ventilator under-assist may lead to muscle injury, while over-assist may result in muscle atrophy. This provides a good rationale to monitor respiratory drive in ventilated patients. Respiratory drive can be monitored by a nasogastric catheter, either with esophageal balloon to determine muscular pressure (gold standard) or with electrodes to measure electrical activity of the diaphragm. A disadvantage is that both techniques are invasive. Therefore, it is interesting to investigate the role of surrogate markers for respiratory dive, such as extradiaphragmatic inspiratory muscle activity. The aim of the current study was to investigate the effect of different inspiratory support levels on the recruitment pattern of extradiaphragmatic inspiratory muscles with respect to the diaphragm and to evaluate agreement between activity of extradiaphragmatic inspiratory muscles and the diaphragm. Methods Activity from the alae nasi, genioglossus, scalene, sternocleidomastoid and parasternal intercostals was recorded using surface electrodes. Electrical activity of the diaphragm was measured using a multi-electrode nasogastric catheter. Pressure support (PS) levels were reduced from 15 to 3 cmH2O every 5 min with steps of 3 cmH2O. The magnitude and timing of respiratory muscle activity were assessed. Results We included 17 ventilated patients. Diaphragm and extradiaphragmatic inspiratory muscle activity increased in response to lower PS levels (36 ± 6% increase for the diaphragm, 30 ± 6% parasternal intercostals, 41 ± 6% scalene, 40 ± 8% sternocleidomastoid, 43 ± 6% alae nasi and 30 ± 6% genioglossus). Changes in diaphragm activity correlated best with changes in alae nasi activity (r2 = 0.49; P < 0.001), while there was no correlation between diaphragm and sternocleidomastoid activity. The agreement between diaphragm and extradiaphragmatic inspiratory muscle activity was low due to a high individual variability. Onset of alae nasi activity preceded the onset of all other muscles. Conclusions Extradiaphragmatic inspiratory muscle activity increases in response to lower inspiratory support levels. However, there is a poor correlation and agreement with the change in diaphragm activity, limiting the use of surface electromyography (EMG) recordings of extradiaphragmatic inspiratory muscles as a surrogate for electrical activity of the diaphragm.
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Affiliation(s)
- L H Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - J Doorduin
- Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Postbox 7057, 1007 MB, Amsterdam, The Netherlands.
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22
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Umbrello M, Formenti P, Lusardi AC, Guanziroli M, Caccioppola A, Coppola S, Chiumello D. Oesophageal pressure and respiratory muscle ultrasonographic measurements indicate inspiratory effort during pressure support ventilation. Br J Anaesth 2020; 125:e148-e157. [PMID: 32386831 DOI: 10.1016/j.bja.2020.02.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/03/2020] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bedside measures of patient effort are essential to properly titrate the level of pressure support ventilation. We investigated whether the tidal swing in oesophageal (ΔPes) and transdiaphragmatic pressure (ΔPdi), and ultrasonographic changes in diaphragm (TFdi) and parasternal intercostal (TFic) thickening are reliable estimates of respiratory effort. The effect of diaphragm dysfunction was also considered. METHODS Twenty-one critically ill patients were enrolled: age 73 (14) yr, BMI 27 (7) kg m-2, and Pao2/Fio2 33.3 (9.2) kPa. A three-level pressure support trial was performed: baseline, 25% (PS-medium), and 50% reduction (PS-low). We recorded the oesophageal and transdiaphragmatic pressure-time products (PTPs), work of breathing (WOB), and diaphragm and intercostal ultrasonography. Diaphragm dysfunction was defined by the Gilbert index. RESULTS Pressure support was 9.0 (1.6) cm H2O at baseline, 6.7 (1.3) (PS-medium), and 4.4 (1.0) (PS-low). ΔPes was significantly associated with the oesophageal PTP (R2=0.868; P<0.001) and the WOB (R2=0.683; P<0.001). ΔPdi was significantly associated with the transdiaphragmatic PTP (R2=0.820; P<0.001). TFdi was only weakly correlated with the oesophageal PTP (R2=0.326; P<0.001), and the correlation improved after excluding patients with diaphragm dysfunction (R2=0.887; P<0.001). TFdi was higher and TFic lower in patients without diaphragm dysfunction: 33.6 (18.2)% vs 13.2 (9.2)% and 2.1 (1.7)% vs 12.7 (9.1)%; P<0.0001. CONCLUSIONS ΔPes and ΔPdi are adequate estimates of inspiratory effort. Diaphragm ultrasonography is a reliable indicator of inspiratory effort in the absence of diaphragm dysfunction. Additional measurement of parasternal intercostal thickening may discriminate a low inspiratory effort or a high effort in the presence of a dysfunctional diaphragm.
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Affiliation(s)
- Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Andrea C Lusardi
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milan, Italy
| | | | - Alessio Caccioppola
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milan, Italy
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy; Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milan, Italy; Centro Ricerca Coordinata di Insufficienza Respiratoria, Università Degli Studi di Milano, Milan, Italy.
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23
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Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory Drive in Critically Ill Patients. Pathophysiology and Clinical Implications. Am J Respir Crit Care Med 2020; 201:20-32. [DOI: 10.1164/rccm.201903-0596so] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; and
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
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24
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Akoumianaki E, Vaporidi K, Georgopoulos D. The Injurious Effects of Elevated or Nonelevated Respiratory Rate during Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:149-157. [PMID: 30199652 DOI: 10.1164/rccm.201804-0726ci] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory rate is one of the key variables that is set and monitored during mechanical ventilation. As part of increasing efforts to optimize mechanical ventilation, it is prudent to expand understanding of the potential harmful effects of not only volume and pressures but also respiratory rate. The mechanisms by which respiratory rate may become injurious during mechanical ventilation can be distinguished in two broad categories. In the first, well-recognized category, concerning both controlled and assisted ventilation, the respiratory rate per se may promote ventilator-induced lung injury, dynamic hyperinflation, ineffective efforts, and respiratory alkalosis. It may also be misinterpreted as distress delaying the weaning process. In the second category, which concerns only assisted ventilation, the respiratory rate may induce injury in a less apparent way by remaining relatively quiescent while being challenged by chemical feedback. By responding minimally to chemical feedback, respiratory rate leaves the control of V. e almost exclusively to inspiratory effort. In such cases, when assist is high, weak inspiratory efforts promote ineffective triggering, periodic breathing, and diaphragmatic atrophy. Conversely, when assist is low, diaphragmatic efforts are intense and increase the risk for respiratory distress, asynchronies, ventilator-induced lung injury, diaphragmatic injury, and cardiovascular complications. This review thoroughly presents the multiple mechanisms by which respiratory rate may induce injury during mechanical ventilation, drawing the attention of critical care physicians to the potential injurious effects of respiratory rate insensitivity to chemical feedback during assisted ventilation.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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25
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Bertoni M, Telias I, Urner M, Long M, Del Sorbo L, Fan E, Sinderby C, Beck J, Liu L, Qiu H, Wong J, Slutsky AS, Ferguson ND, Brochard LJ, Goligher EC. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:346. [PMID: 31694692 PMCID: PMC6836358 DOI: 10.1186/s13054-019-2617-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/20/2019] [Indexed: 01/12/2023]
Abstract
Background Excessive respiratory muscle effort during mechanical ventilation may cause patient self-inflicted lung injury and load-induced diaphragm myotrauma, but there are no non-invasive methods to reliably detect elevated transpulmonary driving pressure and elevated respiratory muscle effort during assisted ventilation. We hypothesized that the swing in airway pressure generated by respiratory muscle effort under assisted ventilation when the airway is briefly occluded (ΔPocc) could be used as a highly feasible non-invasive technique to screen for these conditions. Methods Respiratory muscle pressure (Pmus), dynamic transpulmonary driving pressure (ΔPL,dyn, the difference between peak and end-expiratory transpulmonary pressure), and ΔPocc were measured daily in mechanically ventilated patients in two ICUs in Toronto, Canada. A conversion factor to predict ΔPL,dyn and Pmus from ΔPocc was derived and validated using cross-validation. External validity was assessed in an independent cohort (Nanjing, China). Results Fifty-two daily recordings were collected in 16 patients. In this sample, Pmus and ΔPL were frequently excessively high: Pmus exceeded 10 cm H2O on 84% of study days and ΔPL,dyn exceeded 15 cm H2O on 53% of study days. ΔPocc measurements accurately detected Pmus > 10 cm H2O (AUROC 0.92, 95% CI 0.83–0.97) and ΔPL,dyn > 15 cm H2O (AUROC 0.93, 95% CI 0.86–0.99). In the external validation cohort (n = 12), estimating Pmus and ΔPL,dyn from ΔPocc measurements detected excessively high Pmus and ΔPL,dyn with similar accuracy (AUROC ≥ 0.94). Conclusions Measuring ΔPocc enables accurate non-invasive detection of elevated respiratory muscle pressure and transpulmonary driving pressure. Excessive respiratory effort and transpulmonary driving pressure may be frequent in spontaneously breathing ventilated patients.
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Affiliation(s)
- Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili di Brescia, University of Brescia, UNIBS, Brescia, Italy.,Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, UNIBS, Brescia, Italy
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Michael Long
- Respiratory Therapy, University Health Network, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jennifer Beck
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jenna Wong
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada. .,Toronto General Hospital Research Institute, Toronto, Canada. .,Toronto General Hospital, 585 University Ave., Peter Munk Building, 11th Floor, Room 192, Toronto, ON, M5G 2N2, Canada.
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26
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Double Cycling During Mechanical Ventilation: Frequency, Mechanisms, and Physiologic Implications. Crit Care Med 2019; 46:1385-1392. [PMID: 29985211 DOI: 10.1097/ccm.0000000000003256] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Double cycling generates larger than expected tidal volumes that contribute to lung injury. We analyzed the incidence, mechanisms, and physiologic implications of double cycling during volume- and pressure-targeted mechanical ventilation in critically ill patients. DESIGN Prospective, observational study. SETTING Three general ICUs in Spain. PATIENTS Sixty-seven continuously monitored adult patients undergoing volume control-continuous mandatory ventilation with constant flow, volume control-continuous mandatory ventilation with decelerated flow, or pressure control-continuous mandatory mechanical ventilation for longer than 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 9,251 hours of mechanical ventilation corresponding to 9,694,573 breaths. Double cycling occurred in 0.6%. All patients had double cycling; however, the distribution of double cycling varied over time. The mean percentage (95% CI) of double cycling was higher in pressure control-continuous mandatory ventilation 0.54 (0.34-0.87) than in volume control-continuous mandatory ventilation with constant flow 0.27 (0.19-0.38) or volume control-continuous mandatory ventilation with decelerated flow 0.11 (0.06-0.20). Tidal volume in double-cycled breaths was higher in volume control-continuous mandatory ventilation with constant flow and volume control-continuous mandatory ventilation with decelerated flow than in pressure control-continuous mandatory ventilation. Double-cycled breaths were patient triggered in 65.4% and reverse triggered (diaphragmatic contraction stimulated by a previous passive ventilator breath) in 34.6% of cases; the difference was largest in volume control-continuous mandatory ventilation with decelerated flow (80.7% patient triggered and 19.3% reverse triggered). Peak pressure of the second stacked breath was highest in volume control-continuous mandatory ventilation with constant flow regardless of trigger type. Various physiologic factors, none mutually exclusive, were associated with double cycling. CONCLUSIONS Double cycling is uncommon but occurs in all patients. Periods without double cycling alternate with periods with clusters of double cycling. The volume of the stacked breaths can double the set tidal volume in volume control-continuous mandatory ventilation with constant flow. Gas delivery must be tailored to neuroventilatory demand because interdependent ventilator setting-related physiologic factors can contribute to double cycling. One third of double-cycled breaths were reverse triggered, suggesting that repeated respiratory muscle activation after time-initiated ventilator breaths occurs more often than expected.
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Piquilloud L, Beloncle F, Richard JCM, Mancebo J, Mercat A, Brochard L. Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study. Ann Intensive Care 2019; 9:89. [PMID: 31414251 PMCID: PMC6692797 DOI: 10.1186/s13613-019-0564-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed. Methods Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure–time product (PTPeso) and work of breathing (WOB) were calculated offline. Results Median [interquartile range] peak Eadi at baseline was 17 [13–22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6–27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels. Conclusion Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013 Electronic supplementary material The online version of this article (10.1186/s13613-019-0564-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lise Piquilloud
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France. .,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - François Beloncle
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Jean-Christophe M Richard
- SAMU74, Emergency Department, General Hospital of Annecy, 1, Av de l'hôpital, 74370, Epagny Metz-Tessy, France.,INSERM, UMR 955, Créteil, France
| | - Jordi Mancebo
- Intensive Care Department, Sant Pau Hospital, Carrer de Sant Quinti 89, 08041, Barcelona, Spain
| | - Alain Mercat
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
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28
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain
- Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Universidad Europea, Madrid, Spain
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29
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Tagliabue G, Ji M, Suneby Jagers JV, Zuege DJ, Kortbeek JB, Easton PA. Distinct neural-mechanical efficiency of costal and crural diaphragm during hypercapnia. Respir Physiol Neurobiol 2019; 268:103247. [PMID: 31247325 DOI: 10.1016/j.resp.2019.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/30/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
Abstract
Classic physiology suggests that the two distinct diaphragm segments, costal and crural, are functionally different. It is not known if the two diaphragm muscles share a common neural mechanical activation. We hypothesized that costal and crural diaphragm are recruited differently during hypercapnic stimulated ventilation, and the EMG recordings of the esophageal crural diaphragm segment does not translate to the same level of mechanical shortening for costal and crural segments In 30 spontaneously breathing canines, without confounding anesthetic, we measured directly electrical activity and corresponding mechanical shortening of both the costal and crural diaphragm, at room air and during increasing hypercapnia. During hypercapnic ventilation, the costal diaphragm showed a predominant recruitment over the crural diaphragm. The distinct mechanical contribution of the costal segment was not due to a different level of neural activation between the two muscles as measured by segmental EMG activity. Thus, the two diaphragm segments exhibited a significantly different neural-mechanical relationship.
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Affiliation(s)
- Giovanni Tagliabue
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Michael Ji
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Jenny V Suneby Jagers
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Dan J Zuege
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - John B Kortbeek
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Paul A Easton
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada.
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30
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Tang H, Shrager JB. The Signaling Network Resulting in Ventilator-induced Diaphragm Dysfunction. Am J Respir Cell Mol Biol 2019; 59:417-427. [PMID: 29768017 DOI: 10.1165/rcmb.2018-0022tr] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving measure for those incapable of adequately ventilating or oxygenating without assistance. Unfortunately, even brief periods of MV result in diaphragm weakness (i.e., ventilator-induced diaphragm dysfunction [VIDD]) that may render it difficult to wean the ventilator. Prolonged MV is associated with cascading complications and is a strong risk factor for death. Thus, prevention of VIDD may have a dramatic impact on mortality rates. Here, we summarize the current understanding of the pathogenic events underlying VIDD. Numerous alterations have been proven important in both human and animal MV diaphragm. These include protein degradation via the ubiquitin proteasome system, autophagy, apoptosis, and calpain activity-all causing diaphragm muscle fiber atrophy, altered energy supply via compromised oxidative phosphorylation and upregulation of glycolysis, and also mitochondrial dysfunction and oxidative stress. Mitochondrial oxidative stress in fact appears to be a central factor in each of these events. Recent studies by our group and others indicate that mitochondrial function is modulated by several signaling molecules, including Smad3, signal transducer and activator of transcription 3, and FoxO. MV rapidly activates Smad3 and signal transducer and activator of transcription 3, which upregulate mitochondrial oxidative stress. Additional roles may be played by angiotensin II and leaky ryanodine receptors causing elevated calcium levels. We present, here, a hypothetical scaffold for understanding the molecular pathogenesis of VIDD, which links together these elements. These pathways harbor several drug targets that could soon move toward testing in clinical trials. We hope that this review will shape a short list of the most promising candidates.
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Affiliation(s)
- Huibin Tang
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Joseph B Shrager
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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31
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Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV). J Pediatr 2019; 205:112-119.e4. [PMID: 30448014 DOI: 10.1016/j.jpeds.2018.09.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION Clinicaltrials.gov: NCT02602678.
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32
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Stripoli T, Spadaro S, Di Mussi R, Volta CA, Trerotoli P, De Carlo F, Iannuzziello R, Sechi F, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow oxygen therapy in tracheostomized patients at high risk of weaning failure. Ann Intensive Care 2019; 9:4. [PMID: 30617626 PMCID: PMC6323064 DOI: 10.1186/s13613-019-0482-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose High-flow oxygen therapy delivered through nasal cannulae improves oxygenation and decreases work of breathing in critically ill patients. Little is known of the physiological effects of high-flow oxygen therapy applied to the tracheostomy cannula (T-HF). In this study, we compared the effects of T-HF or conventional low-flow oxygen therapy (conventional O2) on neuro-ventilatory drive, work of breathing, respiratory rate (RR) and gas exchange, in a mixed population of tracheostomized patients at high risk of weaning failure. Methods This was a single-center, unblinded, cross-over study on fourteen patients. After disconnection from the ventilator, each patient received two 1-h periods of T-HF (T-HF1 and T-HF2) alternated with 1 h of conventional O2. The inspiratory oxygen fraction was titrated to achieve an arterial O2 saturation target of 94–98% (88–92% in COPD patients). We recorded neuro-ventilatory drive (electrical diaphragmatic activity, EAdi), work of breathing (inspiratory muscular pressure–time product per breath and per minute, PTPmusc/b and PTPmusc/min, respectively) respiratory rate and arterial blood gases. Results The EAdipeak remained unchanged (mean ± SD) in the T-HF1, conventional O2 and T-HF2 study periods (8.8 ± 4.3 μV vs 8.9 ± 4.8 μV vs 9.0 ± 4.1 μV, respectively, p = 0.99). Similarly, PTPmusc/b and PTPmusc/min, RR and gas exchange remained unchanged. Conclusions In tracheostomized patients at high risk of weaning failure from mechanical ventilation, T-HF did not improve neuro-ventilatory drive, work of breathing, respiratory rate and gas exchange compared with conventional O2 after disconnection from the ventilator. The present findings might suggest that physiological effects of high-flow therapy through tracheostomy substantially differ from nasal high flow.
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Affiliation(s)
- Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Francesca De Carlo
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Rachele Iannuzziello
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Fabio Sechi
- Dipartimento di Scienze Chirurgiche e Microchirurgiche, Università degli Studi di Sassari, Sassari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, King's College London, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy.
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Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, Ruiz S, Rouget A, Delmas C, Seguin T, Minville V, Georges B. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2. [PMID: 30616669 PMCID: PMC6323755 DOI: 10.1186/s13054-018-2288-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
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Affiliation(s)
- Olivier Lamouret
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France. .,Department of Anaesthesiology and Critical Care Unit, University Hospital of Toulouse, 31059, Toulouse Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Fanny Vardon Bounes
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Caroline Dilasser
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thibaut Raimondi
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Stephanie Ruiz
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Clément Delmas
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thierry Seguin
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
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Grieco DL, Bitondo MM, Aguirre-Bermeo H, Italiano S, Idone FA, Moccaldo A, Santantonio MT, Eleuteri D, Antonelli M, Mancebo J, Maggiore SM. Patient-ventilator interaction with conventional and automated management of pressure support during difficult weaning from mechanical ventilation. J Crit Care 2018; 48:203-210. [DOI: 10.1016/j.jcrc.2018.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/21/2022]
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35
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Jansen D, Jonkman AH, Roesthuis L, Gadgil S, van der Hoeven JG, Scheffer GJJ, Girbes A, Doorduin J, Sinderby CS, Heunks LMA. Estimation of the diaphragm neuromuscular efficiency index in mechanically ventilated critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:238. [PMID: 30261920 PMCID: PMC6161422 DOI: 10.1186/s13054-018-2172-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022]
Abstract
Background Diaphragm dysfunction develops frequently in ventilated intensive care unit (ICU) patients. Both disuse atrophy (ventilator over-assist) and high respiratory muscle effort (ventilator under-assist) seem to be involved. A strong rationale exists to monitor diaphragm effort and titrate support to maintain respiratory muscle activity within physiological limits. Diaphragm electromyography is used to quantify breathing effort and has been correlated with transdiaphragmatic pressure and esophageal pressure. The neuromuscular efficiency index (NME) can be used to estimate inspiratory effort, however its repeatability has not been investigated yet. Our goal is to evaluate NME repeatability during an end-expiratory occlusion (NMEoccl) and its use to estimate the pressure generated by the inspiratory muscles (Pmus). Methods This is a prospective cohort study, performed in a medical-surgical ICU. A total of 31 adult patients were included, all ventilated in neurally adjusted ventilator assist (NAVA) mode with an electrical activity of the diaphragm (EAdi) catheter in situ. At four time points within 72 h five repeated end-expiratory occlusion maneuvers were performed. NMEoccl was calculated by delta airway pressure (ΔPaw)/ΔEAdi and was used to estimate Pmus. The repeatability coefficient (RC) was calculated to investigate the NMEoccl variability. Results A total number of 459 maneuvers were obtained. At time T = 0 mean NMEoccl was 1.22 ± 0.86 cmH2O/μV with a RC of 82.6%. This implies that when NMEoccl is 1.22 cmH2O/μV, it is expected with a probability of 95% that the subsequent measured NMEoccl will be between 2.22 and 0.22 cmH2O/μV. Additional EAdi waveform analysis to correct for non-physiological appearing waveforms, did not improve NMEoccl variability. Selecting three out of five occlusions with the lowest variability reduced the RC to 29.8%. Conclusions Repeated measurements of NMEoccl exhibit high variability, limiting the ability of a single NMEoccl maneuver to estimate neuromuscular efficiency and therefore the pressure generated by the inspiratory muscles based on EAdi. Electronic supplementary material The online version of this article (10.1186/s13054-018-2172-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Lisanne Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gert-Jan J Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Armand Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands.
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36
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Di Mussi R, Spadaro S, Stripoli T, Volta CA, Trerotoli P, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:180. [PMID: 30071876 PMCID: PMC6091018 DOI: 10.1186/s13054-018-2107-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The physiological effects of high-flow nasal cannula O2 therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O2 therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure. METHODS This was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O2 therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O2 saturation target of 88-92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTPDI/min)) were recorded. RESULTS EAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 μV switching from HFNC1 to conventional O2, and then returned to 15.2 ± 6.4 μV during HFNC2 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). Similarly, the PTPDI/min increased from 135 ± 60 to 211 ± 70 cmH2O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). CONCLUSIONS In patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O2 therapy.
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Affiliation(s)
- Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
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Telias I, Brochard L, Goligher EC. Is my patient's respiratory drive (too) high? Intensive Care Med 2018; 44:1936-1939. [PMID: 29497778 DOI: 10.1007/s00134-018-5091-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada.,Santorio Mater Dei, Buenos Aires, Argentina
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
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Liu L, Wu AP, Yang Y, Liu SQ, Huang YZ, Xie JF, Pan C, Yang CS, Qiu HB. Effects of Propofol on Respiratory Drive and Patient-ventilator Synchrony during Pressure Support Ventilation in Postoperative Patients: A Prospective Study. Chin Med J (Engl) 2018; 130:1155-1160. [PMID: 28485314 PMCID: PMC5443020 DOI: 10.4103/0366-6999.205864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Propofol is increasingly used during partial support mechanical ventilation such as pressure support ventilation (PSV) in postoperative patients. However, breathing pattern, respiratory drive, and patient-ventilator synchrony are affected by the sedative used and the sedation depth. The present study aimed to evaluate the physiologic effects of varying depths of propofol sedation on respiratory drive and patient-ventilator synchrony during PSV in postoperative patients. METHODS Eight postoperative patients receiving PSV for <24 h were enrolled. Propofol was administered to achieve and maintain a Ramsay score of 4, and the inspiratory pressure support was titrated to obtain a tidal volume (VT) of 6-8 ml/kg. Then, the propofol dose was reduced to achieve and maintain a Ramsay score of 3 and then 2. At each Ramsay level, the patient underwent 30-min trials of PSV. We measured the electrical activity of the diaphragm, flow, airway pressure, neuro-ventilatory efficiency (NVE), and patient-ventilator synchrony. RESULTS Increasing the depth of sedation reduced the peak and mean electrical activity of the diaphragm, which suggested a decrease in respiratory drive, while VT remained unchanged. The NVE increased with an increase in the depth of sedation. Minute ventilation and inspiratory duty cycle decreased with an increase in the depth of sedation, but this only achieved statistical significance between Ramsay 2 and both Ramsay 4 and 3 (P < 0.05). The ineffective triggering index increased with increasing sedation depth (9.5 ± 4.0%, 6.7 ± 2.0%, and 4.2 ± 2.1% for Ramsay 4, 3, and 2, respectively) and achieved statistical significance between each pair of depth of sedation (P < 0.05). The depth of sedation did not affect gas exchange. CONCLUSIONS Propofol inhibits respiratory drive and deteriorates patient-ventilator synchrony to the extent that varies with the depth of sedation. Propofol has less effect on breathing pattern and has no effect on VT and gas exchange in postoperative patients with PSV.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ai-Ping Wu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Song-Qiao Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ying-Zi Huang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Jian-Feng Xie
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Chun Pan
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Cong-Shan Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Hai-Bo Qiu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
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Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, Vorona S, Sklar MC, Rittayamai N, Lanys A, Murray A, Brace D, Urrea C, Reid WD, Tomlinson G, Slutsky AS, Kavanagh BP, Brochard LJ, Ferguson ND. Mechanical Ventilation–induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes. Am J Respir Crit Care Med 2018; 197:204-213. [DOI: 10.1164/rccm.201703-0536oc] [Citation(s) in RCA: 298] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine
- Department of Physiology
- Department of Medicine
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Martin Dres
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Respiratory and Critical Care Department, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Institute for Health Policy, Management, and Evaluation
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Gordon D. Rubenfeld
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Institute for Health Policy, Management, and Evaluation
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Institute for Health Policy, Management, and Evaluation
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada
| | - Margaret S. Herridge
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada; and
| | - Stefannie Vorona
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Michael C. Sklar
- Department of Anesthesia, and
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Nuttapol Rittayamai
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Ashley Lanys
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Alistair Murray
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Deborah Brace
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Cristian Urrea
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - W. Darlene Reid
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Brian P. Kavanagh
- Interdepartmental Division of Critical Care Medicine
- Department of Physiology
- Department of Anesthesia, and
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
| | - Laurent J. Brochard
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine
- Department of Physiology
- Department of Medicine
- Institute for Health Policy, Management, and Evaluation
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
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40
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Oppersma E, Doorduin J, van der Hoeven JG, Veltink PH, van Hees HWH, Heunks LMA. The effect of metabolic alkalosis on the ventilatory response in healthy subjects. Respir Physiol Neurobiol 2018; 249:47-53. [PMID: 29307724 DOI: 10.1016/j.resp.2018.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/07/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with acute respiratory failure may develop respiratory acidosis. Metabolic compensation by bicarbonate production or retention results in posthypercapnic alkalosis with an increased arterial bicarbonate concentration. The hypothesis of this study was that elevated plasma bicarbonate levels decrease respiratory drive and minute ventilation. METHODS In an intervention study in 10 healthy subjects the ventilatory response using a hypercapnic ventilatory response (HCVR) test was assessed, before and after administration of high dose sodium bicarbonate. Total dose of sodiumbicarbonate was 1000 ml 8.4% in 3 days. RESULTS Plasma bicarbonate increased from 25.2 ± 2.2 to 29.2 ± 1.9 mmol/L. With increasing inspiratory CO2 pressure during the HCVR test, RR, Vt, Pdi, EAdi and VE increased. The clinical ratio ΔVE/ΔPetCO2 remained unchanged, but Pdi, EAdi and VE were significantly lower after bicarbonate administration for similar levels of inspired CO2. CONCLUSION This study demonstrates that in healthy subjects metabolic alkalosis decreases the neural respiratory drive and minute ventilation, as a response to inspiratory CO2.
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Affiliation(s)
- E Oppersma
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Doorduin
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P H Veltink
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands
| | - H W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M A Heunks
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Koyama Y, Yoshida T, Uchiyama A, Fujino Y. Monitoring diaphragm function in a patient with myasthenia gravis: electrical activity of the diaphragm vs. maximal inspiratory pressure. J Intensive Care 2017; 5:66. [PMID: 29209502 PMCID: PMC5704593 DOI: 10.1186/s40560-017-0262-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Maximal inspiratory pressure (MIP) is used to assess respiratory muscle strength of patients with myasthenia gravis (MG) requiring ventilatory support. Electrical activity of the diaphragm (E-di) has been used to guide weaning. Case presentation The MIP and tidal volume/ΔE-di (the patient-to-ventilator breath contribution) were monitored in a 12-year-old girl with MG requiring ventilator support. The same ventilatory settings were maintained until extubation. During weaning, MIP increased slightly, but varied unpredictably. Tidal volume/ΔE-di decreased at a constant rate as muscle strength recovered. Conclusion In this patient with muscle weakness, E-di was a reliable tool to monitor weaning from mechanical ventilation.
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Affiliation(s)
- Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan.,Physiology and Experimental Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, ON M5G 0A4 Canada
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
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Prevalence and Prognosis Impact of Patient-Ventilator Asynchrony in Early Phase of Weaning according to Two Detection Methods. Anesthesiology 2017; 127:989-997. [PMID: 28914623 DOI: 10.1097/aln.0000000000001886] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patient-ventilator asynchrony is associated with a poorer outcome. The prevalence and severity of asynchrony during the early phase of weaning has never been specifically described. The authors' first aim was to evaluate the prognosis impact and the factors associated with asynchrony. Their second aim was to compare the prevalence of asynchrony according to two methods of detection: a visual inspection of signals and a computerized method integrating electromyographic activity of the diaphragm. METHODS This was an ancillary study of a multicenter, randomized controlled trial comparing neurally adjusted ventilatory assist to pressure support ventilation. Asynchrony was quantified at 12, 24, 36, and 48 h after switching from controlled ventilation to a partial mode of ventilatory assistance according to the two methods. An asynchrony index greater than or equal to 10% defined severe asynchrony. RESULTS A total of 103 patients ventilated for a median duration of 5 days (interquartile range, 3 to 9 days) were included. Whatever the method used for quantification, severe patient-ventilator asynchrony was not associated with an alteration of the outcome. No factor was associated with severe asynchrony. The prevalence of asynchrony was significantly lower when the quantification was based on flow and pressure than when it was based on the electromyographic activity of the diaphragm at 0.3 min (interquartile range, 0.2 to 0.8 min) and 4.7 min (interquartile range, 3.2 to 7.7 min; P < 0.0001), respectively. CONCLUSIONS During the early phase of weaning in patients receiving a partial ventilatory mode, severe patient-ventilator asynchrony was not associated with adverse clinical outcome, although the prevalence of patient-ventilator asynchrony varies according to the definitions and methods used for detection.
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Tang H, L Kennedy C, Lee M, Gao Y, Xia H, Olguin F, Fraga DA, Ayers K, Choi S, Kim M, Tehrani A, Sowb YA, Rando TA, Shrager JB. Smad3 initiates oxidative stress and proteolysis that underlies diaphragm dysfunction during mechanical ventilation. Sci Rep 2017; 7:14530. [PMID: 29109401 DOI: 10.1038/s41598-017-11978-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 08/23/2017] [Indexed: 01/08/2023] Open
Abstract
Prolonged use of mechanical ventilation (MV) leads to atrophy and dysfunction of the major inspiratory muscle, the diaphragm, contributing to ventilator dependence. Numerous studies have shown that proteolysis and oxidative stress are among the major effectors of ventilator-induced diaphragm muscle dysfunction (VIDD), but the upstream initiator(s) of this process remain to be elucidated. We report here that periodic diaphragm contraction via phrenic nerve stimulation (PNS) substantially reduces MV-induced proteolytic activity and oxidative stress in the diaphragm. We show that MV rapidly induces phosphorylation of Smad3, and PNS nearly completely prevents this effect. In cultured cells, overexpressed Smad3 is sufficient to induce oxidative stress and protein degradation, whereas inhibition of Smad3 activity suppresses these events. In rats subjected to MV, inhibition of Smad3 activity by SIS3 suppresses oxidative stress and protein degradation in the diaphragm and prevents the reduction in contractility that is induced by MV. Smad3's effect appears to link to STAT3 activity, which we previously identified as a regulator of VIDD. Inhibition of Smad3 suppresses STAT3 signaling both in vitro and in vivo. Thus, MV-induced diaphragm inactivity initiates catabolic changes via rapid activation of Smad3 signaling. An early intervention with PNS and/or pharmaceutical inhibition of Smad3 may prevent clinical VIDD.
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Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Catherine L Kennedy
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Myung Lee
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Yang Gao
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Hui Xia
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Thoracic-cardio Surgery, First Affiliated Hospital of PLA General Hospital, Beijing, China
| | - Francesca Olguin
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Danielle A Fraga
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Kelsey Ayers
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sehoon Choi
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Michael Kim
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Amir Tehrani
- Respiratory Management Technologies, LLC., San Francisco, CA, USA
| | - Yasser A Sowb
- Respiratory Management Technologies, LLC., San Francisco, CA, USA
| | - Thomas A Rando
- VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Paul F. Glenn Laboratories for the Biology of Aging and Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA. .,VA Palo Alto Healthcare System, Palo Alto, CA, USA.
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Pham T, Brochard LJ, Slutsky AS. Mechanical Ventilation: State of the Art. Mayo Clin Proc 2017; 92:1382-1400. [PMID: 28870355 DOI: 10.1016/j.mayocp.2017.05.004] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/03/2017] [Accepted: 05/01/2017] [Indexed: 02/07/2023]
Abstract
Mechanical ventilation is the most used short-term life support technique worldwide and is applied daily for a diverse spectrum of indications, from scheduled surgical procedures to acute organ failure. This state-of-the-art review provides an update on the basic physiology of respiratory mechanics, the working principles, and the main ventilatory settings, as well as the potential complications of mechanical ventilation. Specific ventilatory approaches in particular situations such as acute respiratory distress syndrome and chronic obstructive pulmonary disease are detailed along with protective ventilation in patients with normal lungs. We also highlight recent data on patient-ventilator dyssynchrony, humidified high-flow oxygen through nasal cannula, extracorporeal life support, and the weaning phase. Finally, we discuss the future of mechanical ventilation, addressing avenues for improvement.
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Affiliation(s)
- Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
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Pellegrini M, Hedenstierna G, Roneus A, Segelsjö M, Larsson A, Perchiazzi G. The Diaphragm Acts as a Brake during Expiration to Prevent Lung Collapse. Am J Respir Crit Care Med 2017; 195:1608-1616. [PMID: 27922742 DOI: 10.1164/rccm.201605-0992oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE The diaphragm is the major inspiratory muscle and is assumed to relax during expiration. However, electrical postinspiratory activity has been observed. Whether there is an expiratory diaphragmatic contraction that preserves lung patency has yet to be explored. OBJECTIVES We hypothesized the occurrence of an expiratory diaphragmatic contraction directed at stabilizing peripheral airways and preventing or reducing cyclic expiratory lung collapse. METHODS Mild acute respiratory distress syndrome was induced in 10 anesthetized, spontaneously breathing pigs. Lung volume was decreased by lowering end-expiratory airway pressure in a stepwise manner. We recorded the diaphragmatic electric activity during expiration, dynamic computed tomographic scans, and respiratory mechanics. In five pigs, the same protocol was repeated during mechanical ventilation after muscle paralysis. MEASUREMENTS AND MAIN RESULTS Diaphragmatic electric activity during expiration increased by decreasing end-expiratory lung volume during spontaneous breathing. This enhanced the diaphragm muscle force, to a greater extent with lower lung volume, indicating a diaphragmatic electromechanical coupling during spontaneous expiration. In turn, the resulting diaphragmatic contraction delayed and reduced the expiratory collapse and increased lung aeration compared with mechanical ventilation with muscle paralysis and absence of diaphragmatic activity. CONCLUSIONS The diaphragm is an important regulator of expiration. Its expiratory activity seems to preserve lung volume and to protect against lung collapse. The loss of diaphragmatic expiratory contraction during mechanical ventilation and muscle paralysis may be a contributing factor to unsuccessful respiratory support.
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Affiliation(s)
- Mariangela Pellegrini
- 1 Hedenstierna Laboratory, Department of Surgical Sciences.,2 Department of Emergency and Organ Transplant, University of Bari, Bari, Italy
| | | | - Agneta Roneus
- 1 Hedenstierna Laboratory, Department of Surgical Sciences
| | - Monica Segelsjö
- 4 Section of Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; and
| | - Anders Larsson
- 1 Hedenstierna Laboratory, Department of Surgical Sciences
| | - Gaetano Perchiazzi
- 1 Hedenstierna Laboratory, Department of Surgical Sciences.,2 Department of Emergency and Organ Transplant, University of Bari, Bari, Italy
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Diniz-Silva F, Miethke-Morais A, Alencar AM, Moriya HT, Caruso P, Costa ELV, Ferreira JC. Monitoring the electric activity of the diaphragm during noninvasive positive pressure ventilation: a case report. BMC Pulm Med 2017; 17:91. [PMID: 28623885 PMCID: PMC5473981 DOI: 10.1186/s12890-017-0434-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/08/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In patients with post-extubation respiratory distress, delayed reintubation may worsen clinical outcomes. Objective measures of extubation failure at the bedside are lacking, therefore clinical parameters are currently used to guide the need of reintubation. Electrical activity of the diaphragm (EAdi) provides clinicians with valuable, objective information about respiratory drive and could be used to monitor respiratory effort. CASE PRESENTATION We describe the case of a patient with Chronic Obstructive Pulmonary Disease (COPD), from whom we recorded EAdi during four different ventilatory conditions: 1) invasive mechanical ventilation, 2) spontaneous breathing trial (SBT), 3) unassisted spontaneous breathing, and 4) Noninvasive Positive Pressure Ventilation (NPPV). The patient had been intubated due to an exacerbation of COPD, and after four days of mechanical ventilation, she passed the SBT and was extubated. Clinical signs of respiratory distress were present immediately after extubation, and EAdi increased compared to values obtained during mechanical ventilation. As we started NPPV, EAdi decreased substantially, indicating muscle unloading promoted by NPPV, and we used the EAdi signal to monitor respiratory effort during NPPV. Over the next three days, she was on NPPV for most of the time, with short periods of spontaneous breathing. EAdi remained considerably lower during NPPV than during spontaneous breathing, until the third day, when the difference was no longer clinically significant. She was then weaned from NPPV and discharged from the ICU a few days later. CONCLUSION EAdi monitoring during NPPV provides an objective parameter of respiratory drive and respiratory muscle unloading and may be a useful tool to guide post-extubation ventilatory support. Clinical studies with continuous EAdi monitoring are necessary to clarify the meaning of its absolute values and changes over time.
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Affiliation(s)
- Fabia Diniz-Silva
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Anna Miethke-Morais
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Henrique T. Moriya
- Biomedical Engineering Laboratory, University of São Paulo, São Paulo, Brazil
| | - Pedro Caruso
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo L. V. Costa
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Juliana C. Ferreira
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Salazar Sánchez MB, Hernández Valdivieso AM, Mañanas Villanueva MÁ. Assessment of mechanically ventilated patients intoxicated with organophosphates by a novel surface electromyographic index. J Crit Care 2017; 41:260-267. [PMID: 28599200 DOI: 10.1016/j.jcrc.2017.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/21/2017] [Accepted: 05/20/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE We present a new electromyographic index, named Engagement of Respiratory Muscle (ERM), for assessing the level of participation of respiratory muscles during spontaneous breathing test in patients poisoned with organophosphorus compound. METHODS Diaphragm and sternocleidomastoid muscles activity was recorded by surface electromyography during spontaneous breathing test. A population of 23 patients poisoned with organophosphates and mechanically ventilated, and a control group of 28 healthy subjects were analyzed. RESULTS All patients developed respiratory failure and 48% were diagnosed with intermediate syndrome by medical staff. The ERM index classified the patients in three clusters (p-value<0.005): Cluster I presented more engagement of the sternocleidomastoid compared to diaphragm, Cluster II had low muscle engagement of both muscles and also muscle weakness, Cluster III were characterized for the diaphragm recovery associated with higher engagement. The control group showed a similar muscle engagement to Cluster III. The capacity of ERM index for classifying patients with (sensitivity) and without (specificity) muscle weakness were 90.91% and 100% respectively. CONCLUSIONS The ERM is a promising index to assess the level of participation of respiratory muscle on spontaneous breathing test in patients poisoned with organophosphorus compounds, which could improve the extubation prognosis for these patients.
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Affiliation(s)
- María Bernarda Salazar Sánchez
- Bioinstrumentation and Clinical Engineering Research Group - GIBIC, Bioengineering Department, Engineering Faculty, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellín, Colombia.
| | - Alher Mauricio Hernández Valdivieso
- Bioinstrumentation and Clinical Engineering Research Group - GIBIC, Bioengineering Department, Engineering Faculty, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellín, Colombia.
| | - Miguel Ángel Mañanas Villanueva
- Department of Automatic Control and the Biomedical Engineering Research Centre, Universitat Politècnica de Catalunya, Calle Jordi Girona, 31, 08034 Barcelona, Spain; Biomedical Research Networking center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain.
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Diaphragm electrical activity monitoring as a breakpoint in the management of a tetraplegic child. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:116. [PMID: 28545534 PMCID: PMC5445481 DOI: 10.1186/s13054-017-1702-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Theerawit P, Sutherasan Y, Ball L, Pelosi P. Respiratory monitoring in adult intensive care unit. Expert Rev Respir Med 2017; 11:453-468. [PMID: 28452241 DOI: 10.1080/17476348.2017.1325324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The mortality of patients with respiratory failure has steadily decreased with the advancements in protective ventilation and treatment options. Although respiratory monitoring per se has not been proven to affect the mortality of critically ill patients, it plays a crucial role in patients' care, as it helps to titrate the ventilatory support. Several new monitoring techniques have recently been made available at the bedside. The goals of monitoring comprise alerting physicians to detect the change in the patients' conditions, to improve the understanding of pathophysiology to guide the diagnosis and provide cost-effective clinical management. Areas covered: We performed a review of the recent scientific literature to provide an overview of the different methods used for respiratory monitoring in adult intensive care units, including bedside imaging techniques such as ultrasound and electrical impedance tomography. Expert commentary: Appropriate respiratory monitoring plays an important role in patients with and without respiratory failure as a guiding tool for the optimization of ventilation support, avoiding further complications and decreasing morbidity and mortality. The physician should tailor the monitoring strategy for each individual patient and know how to correctly interpret the data.
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Affiliation(s)
- Pongdhep Theerawit
- a Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Yuda Sutherasan
- a Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Lorenzo Ball
- b IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics , University of Genoa , Genoa , Italy
| | - Paolo Pelosi
- b IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics , University of Genoa , Genoa , Italy
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Abstract
Controlled Mechanical Ventilation may be essential in the setting of severe respiratory failure but consequences to the patient including increased use of sedation and neuromuscular blockade may contribute to delirium, atelectasis, and diaphragm dysfunction. Assisted ventilation allows spontaneous breathing activity to restore physiological displacement of the diaphragm and recruit better perfused lung regions. Pressure Support Ventilation is the most frequently used mode of assisted mechanical ventilation. However, this mode continues to provide a monotonous pattern of support for respiration which is normally a dynamic process. Noisy Pressure Support Ventilation where tidal volume is varied randomly by the ventilator may improve ventilation and perfusion matching but the degree of support is still determined by the ventilator. Two more recent modes of ventilation, Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist (NAVA), allow patient determination of the pattern and depth of ventilation. Proposed advantages of Proportional Assist Ventilation and NAVA include decrease in patient ventilator asynchrony and improved adaptation of ventilator support to changing patient demand. Work of breathing can be normalized with these modes as well. To date, however, a clear pattern of clinical benefit has not been demonstrated. Existing challenges for both of the newer assist modes include monitoring patients with dynamic hyperinflation (auto-positive end expiratory pressure), obstructive lung disease, and air leaks in the ventilator system. NAVA is dependent on consistent transduction of diaphragm activity by an electrode system placed in the esophagus. Longevity of effective support with this technique is unclear.
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